Inpatient Psychiatric Facility Quality Reporting Abstraction Help Resources

Transcription

1 Inpatient Psychiatric Facility Quality Reporting Abstraction Help Resources Telligen Jane Tehel RN, BS Tressa Clemens RN, BSN Abby Gervais BS March 14, 2013

2 Agenda Program Announcements QualityNet Registration Process Change Notice of Participation- Submission Instructions CMS IPF Question and Answer Tool Facility Profiles Abstraction Help Resources Event Tracking Log Paper Abstraction Tools Frequently Asked Questions 2

3 QualityNet Registration Change in instruction for facilities with an existing account Inpatient Psychiatric Facilities new to CMS Hospital Reporting: Register with QualityNet before the IPF begins reporting, regardless of the method used for submitting the data. Identify a QualityNet Administrator who follows the registration process. NOTE: When a facility has participated in another Hospital Reporting Program and has an existing QualityNet account, they do NOT need complete a new registration for participation in the IPFQR Program. 3

4 Mailing the Registration Form Note: Mail original forms. No photocopies accepted. Forms mailed to QualityNet Help Desk. Do NOT mail to Telligen or the QIO. 4

5 Contacts for QualityNet Registration Questions For questions regarding the QualityNet Registration form QualityNet Help Desk 7 a.m. - 7 p.m. CT Monday - Friday qnetsupport@sdps.org Phone: (866) TTY: (877) Fax: (888)

6 Notice of Participation Paper Form Reminders for Completion Must be signed by CEO, not other hospital representatives. Remember to include the facility CCN (provider number). Write legibly. The content will be entered into the Notice of Participation (NOP) application once it is available. Confirm the address is accurate. Do NOT send the NOP to the QualityNet Help desk. Do NOT send by . 6

7 Notice of Participation Paper Form Steps for Completion 1. Read the Notice of Participation Agreement. 2. Enter the Provider ID in the box provided. 3. Select the appropriate action by entering an X in the box. 7

8 NOP Paper Form (continued) Steps for Completion (continued) 4. Read the acknowledgement and pledge statement and indicate agreement by entering an X in the box. 5. Enter the Facility Name. 6. CEO signs the form in the box (not other facility staff). 7. Enter date of CEO signature in the box. 8. Enter CEO address in the box. 8

9 Submitting the Paper NOP form 9

10 Facility Profile Form Reminder When the facility elects to send the completed Facility Profile form by mail, please remember to keep a copy for your records. 10

11 CMS Q&A Tool for IPFQR Program Now Available The Q& A Tool is an alternate source for submitting program questions to the IPF Support Contractor rather than through the IPF- PCH Help Desk. Do not submit the same question to both the Help Desk and the Q&A Tool - choose one source. 11

12 How to access the Q&A Tool To access the application, open an Internet Explorer (IE) window and navigate to Qualitynet.org. ( Internet Explorer 8.0 or higher is the recommended and supported web browser. The current location of the Q&A URL is on the right side of the QualityNet homepage under Questions and Answers. 12

13 QualityNet Home Page 13

14 Inpatient Q&A Page NOTE: Although the Title bar at the top displays as QualityNet, you are in the Q&A Application. You will not use your QualityNet User ID to submit a question unless you set up your registration to use the same User ID. Select the appropriate program. 14

15 Topics for Inpatient Psychiatric Facilities IPF topics and subtopics that are available to select when searching for answers or submitting a new question. Use ONLY IPF topics to direct your question to the correct program. 15

16 Data Collection for HBIPS 2 and 3 (Event Measures) HBIPS 2 Hours of physical restraint use. HBIPS 3 Hours of seclusion use. 16

17 Instructions for Hospital-Based Inpatient Psychiatric Services (HBIPS) Event Tracking log Purpose To serve as an optional help document for facilities to assist with data collection for CMS reporting of measures under the Inpatient Psychiatric Facility Quality Reporting Program. Facilities can choose to track the events daily, weekly, monthly, or quarterly. 17

18 Step 1 Track each event by completing the Numerator and Denominator sections. Suggestion: Print two Event Tracking Logs, one for HBIPS-2: Hours of Physical Restraint and a second for HBIPS-3: Hours of Seclusion use. 18

19 Sample Numerator Section

20 Step 2 Calculate the Numerator Sort or Filter each event per age strata. Add the Total Minutes per age strata. Divide each age strata total by 60 minutes. Enter the totals per age strata into the numerator files of the Total section. 20

21 Numerator Example Example Age strata C had a total of 253 minutes in restraints (or seclusion). Take 253 total minutes in restraints (or seclusion) divided by 60 minutes = The total Numerator for age strata C is hours in restraint (or seclusion). 21

22 Sample of Total Section Numerator

23 Step 3 Calculate the Denominator Add the total number of Inpatient Days in the Denominator section per age strata. Add the total number of Leave Days in the Denominator section per age strata. Subtract the Total Number of Inpatient Day from Total Leave Days per age strata. Multiply by 24 hours. Divide by 1,000 hours. Enter the total into the Denominator fields per age strata in the Total section. 23

24 Screen Shot of Denominator Section

25 Denominator Example Example The Total Inpatient Days for age strata C = 778. The Total Leave Days for age strata C = = 767. Multiply 767 by 24 hours = 18,408 hours. Divide 18,408 hours by 1,000 hours = The total denominator for age strata C =

26 Screen Shot of Total Section Denominator

27 Definition of Leave Day The Specifications Manual for Joint Commission National Quality Measures, defines a leave day as an authorized or unauthorized absence from a facility, excluding discharges, during which the patient is absent from the facility at the time of the daily census and is not under the direct supervision of facility staff while (v2013a1). 27

28 Example of a Leave Day If a patient leaves on 03/01/2013 at 0600 and returns 03/01/2013 at 2359 this is not considered a leave day because the patient returned before the midnight census If a patient leaves 03/01/2013 at 0600 and returns 03/02/2013 at 0900 this is considered 1 leave day because the patient was not in the midnight census for 03/02/

29 Event Measures Abstraction Reminders HBIPS-2 and 3 do not include any events that occur prior to the patient s arrival to the psychiatric unit. Each individual calendar day that a patient is in restraints or seclusion is abstracted independently. If the event goes over the midnight hour there is two event dates and each date would be abstracted independently. For additional information about restraints and seclusion, please refer to the CMS website, Internet Only Manuals. The Interpretive Guidelines (Appendix PP) in the CMS State Operations Manual, Publication , section , Standard Restraint or Seclusion. ( Only-Manuals-IOMs-Items/CMS html) Per the Specifications Manual, up to six decimal places ( ) are to be used when entering the time for physical restraints or seclusion. There should be no rounding when converting from minutes to hours. 29

30 Data Collection for Discharge Measures HBIPS 4-7 HBIPS 4 Patients discharged on multiple antipsychotic medications. HBIPS 5 Patients discharged on multiple antipsychotic medications with appropriate justification. HBIPS 6 Post discharge continuing care plan created. HBIPS 7 Post discharge continuing care plan transmitted to next level of care provider upon discharge. 30

31 Abstraction Paper Tool Hospital-Based Inpatient Psychiatric Services (HBIPS) Paper tool for discharge Measures (HBIPS-4 through HBIPS-7) This paper abstraction tool is provided as an optional, informal mechanism to aid psychiatric facilities and hospital psychiatric units in the collection of the measures for the CMS Inpatient Psychiatric Facility Quality Reporting Program. The tool is designed to collect patient specific data; however, once abstracted, the data will need to be complied and reported to CMS in aggregate. It should be noted that skip logic is not contained within the paper abstraction tool. If there are any questions or concerns regarding use of this paper abstraction tool, please contact the IPFQR Program Support Contractor at 31

32 Abstraction Paper tool for HBIPS Discharge Measures 32

33 Paper Abstraction Tools 4 th Quarter 2012 Use the paper tool for the discharge period October 1, 2012 through December 31, st Quarter 2013 Use the paper tool for the discharge period January 1, 2013 through June 30,

34 Reporting Period for FY Q 2012 (October 1, 2012 through December 31, 2012). 1Q 2013 (January 1, 2013 through March 31, 2013). Data Submission Period- July 1, 2013 through August 15, 2013 by 11:59 P.M. Pacific Time. 34

35 Questions Review of Questions in the Webinar Queue 35

36 Future Webinars Topic - CMS Listening Session on the proposed changes for Inpatient Psychiatric Facility Quality Reporting based on the IPPS proposed rule. Tentative Date: May 2, p.m. 3 p.m. Eastern Time 1 p.m. 2 p.m. Central Time 12 p.m. 1 p.m. Mountain Time 11 a.m. 12 p.m. Pacific Time 36

37 Contact Information Questions regarding the IPFQR Program may be directed to the Telligen help desk, weekdays from 8 a.m. to 5 p.m. Central Time: IPFQR Support Help Desk Phone: (888) IPF-PCHQRSupport@Telligen.org 37